Stockholm Sweden Tina Louise Jordan, PhD Delaware State University Department of Social Work

1. AFRICAN AMERICAN BAPTIST ADULTS: THE DEGREE TO WHICH SELECTEDSOCIAL AND CULTURAL VARIABLES INFLUENCE THE EXECUTION OF ADVANCE DIRECTIVES Stockholm Sweden Tina Louise Jordan, PhD Delaware State University Department of Social Work July 2012

2. Overview • Background of the Research Study • Statement of the Problem • Statement of the Purpose • Significance of the Study • Research Questions • Conceptual Model • Theoretical Framework • Literature Review • Methodology • Results • Implications • Recommendations

3. Background of the Study • Issues surrounding the planning of end-of-life, which has caused resistance among African American Baptist adults have ranged from racism, cultural mistrust, lack of education, lack of resources. • These factors associated with the execution of advance directives have left family members with questions, economic contention, legal fees and guilt. • Conventionally, people plan for the distribution of material things upon their death. However, some do not consider leaving instruction for the medical intervention in the event that they could receive life sustaining treatment although incapacitated.

4. Statement of the Problem With the existence of the Health Care Decision Act(1993)and the advantages associated with the completion of an advance directives, the vast majority of African Americans, between 83.2% and 91.9% , never execute one. An advance directive is a legal document that contains specific wishes of a patient regarding life sustaining treatment in the event of incapacitation. There are two types of advance directives-living will and the durable power of attorney. Living will allows the patient to place their instructions for medical treatment in writing ( advance directive). Durable power of attorney is an authorized representative to initiate an advance directive on a patients behalf.

5. Statement of the Purpose • To examine the degree to which selected social and cultural variables influence the execution of advance directives amongst African American Baptist adults.

6. Significance of The Study • The current research literature has an insufficient number of studies relevant to the degrees to which African American adults execute advance directives. • Additionally, few studies indicate the degree to which African Americans in the various religious denominations engage in the execution of an advance directive. • The United State Census Bureau (2005) contends that The National Baptist Convention has the largest African American denomination of Baptist adults. • The National Baptist Convention Association (2001) approximates over 2000 churches and over 2.5 million members. • To that end, it is paramount for a denomination of this extent of African American people in the United States to familiarize and execute one of the most important tools to manage end-of-life care decisions, an advance directive.

7. Research Questions • RQ#1 To what degree do gender, age, educational status, socio-economic status, marital status, family composition, employment status and racism influence the execution of advance directives in the African American Baptist adult population?

8. Research Questions and Hypotheses (cont’d) • RQ#2 To what degree do gender, age, educational status, socio-economic status, marital status, family composition, employment status and cultural mistrust influence the execution of advance directives in the African American Baptist adult population?

9. Research Questions and Hypotheses(cont’d) • RQ# 3 To what degree do gender, age, educational status, socio-economic status, marital status, family composition, employment status and spirituality influence the execution of advance directives in the African American Baptist adult population?

10. Research Questions and Hypotheses (cont’d) • RQ# 4 To what degree do gender, age, educational status, socio-economic status, marital status, family composition, employment status and cultural competence influence the execution of advance directives in the African American Baptist adult population?

11. Research Questions and Hypotheses(cont’d) • RQ# 5 To what degree do gender, age, educational status, socio-economic status, marital status, family composition, employment status and the fear of death anxiety influence the execution of advance directives in the African American Baptist adult population?

12. Research Questions and Hypotheses ( cont’d) • RQ# 6 To what degree do gender, age, educational status, socio-economic status, marital status, family composition, employment status, racism, cultural mistrust, spirituality, cultural competence and the fear of death anxiety influence the execution of advance directives in the African American Baptist adult population?

13. Conceptualization of the Relationship between Selected Variables

14. Theoretical Framework Broffenbrenner’s Ecological Theoretical Framework • This theory is explored on the person and the environment and the continuous interaction between the two. • Environmental systems ( family, economic and political ) work continuously together producing various results. • Human growth (spiritual, physical, emotional, psychological, social ) are influenced by a multitude of events that occur between the individual and the environment over the course of ones life( Germain & Gitterman, 1979).

15. Conceptualization of the Theoretical Model of Social and Cultural Variables as it Relates to the execution of Advance Directives

17. Bradley(2004) Smedley(2003) Chunn(2002) Akbar(1996) Washington (2007) Martin & Martin ( 2002) Posits that political, social, economic injustices and oppression have influenced that attitudes and behaviors of African Americans concerning end-of-life treatment (advance directives). Contends that slavery and the extremely long catastrophic history of medical experiments of which African Americans were unwilling participants , has manifested to preclude many A.A’s from seeking and receiving equal levels of treatment from medical professionals. Suggests that African American adults have xenophobic memories and distrust of Euro-American hospital and health care staff. Racism is the fundamental impetus that has caused cultural, psychological, and emotional disruptions in the lives of Many African American adults. Review of Related Literature(Racism)

18. Corbie-Smith (1999) Benkert(2006) Colfer, McDill, Natriello, Pallas & Richardson (1990) Washington (2007) Munishi( 2007) Noah(2002) Jackson(2005) Sharav(2001) Contends that African Americans describe cultural mistrust of the medical community as a prominent barrier to participating in the execution of advance directives. Documented racially motivated studies on A.A.’s have been the catalyst to cultural mistrust . (1800) slaves inoculated with small pox (1803)Placing slaves bodies in open pits (1932) Tuskegee Syphilis Study (1963) injection of liver cancer cells (1990) KKI renting contaminated lead homes to A.A in Md. Review of related Literature (Cultural Mistrust)

19. Dalmida(2006) Munishi(2007) Swanson,Crowther, Green & Armstrong(2002) Levin, Chatters & Taylor (2005) The Joint Commission on Accreditation of Organizations (2005) There has been an influx of research, dialogue, and literature regarding the influence of spirituality and religion on health care outcomes. Each hospital, health care facility must address the concept of spirituality with each patient. Spirituality should determine the patient’s denomination beliefs and what spiritual practices are important to the patient. Review of Related Literature (Spirituality)

20. The Patient Self Determination Act(1990) Act requiring most hospitals and healthcare facilities to ask patients whether they have an advance directive. The main provision of the PSDA(1990) states that every hospital or healthcare facility, which receives (Medicare or Medicaid) funding from the federal government, must ensure that each incoming patients receives a statement of rights concerning the right to make healthcare decisions such as an advance directive. Review of Related Literature (Advance Directive)

21. The Health Care Decision Act(1993) Rights to have the form discussed , presented and executed . Review of Related Literature ( cont’d)

22. HCDA(1993) Delineated three situations, which would necessitate such directives. They are : When death is imminent despite the application of life-sustaining procedures, When a patient is in a condition of permanent unconsciousness typically referred to a a “vegetative state,” and When an advanced end-stage condition is progressive, incurable and results in complete physical dependency Review of Related Literature (cont’d)

23. The Health Care Decision Act (1993) With the existence of the HCDA(1993) and advantages associated with having an advance directive , the vast majority of African Americans, between 83.2% and 91.7%, never execute one. For those without an advance directive, healthcare decisions are made by medical personnel, family members, close friends or members of their religious community. Review of Related Literature (cont’d)

24. Koenig(1997) Martinez, Kind, Pezo & Pomerantz(2008) Contends that culture the lens, as well as the emotional filter, through which many view their world, can affect every decision that one makes. Suggests that healthcare staff and practitioners must prepare for quality, sensitive healthcare by adopting empowerment and cultural competence skills. Review of Related Literature (Cultural Competence)

25. Kübler-Ross (1975) Callahan (1999) Lang (1998) Death is a fundamental part of human life and is as expected as birth. The fear of dying may be a possible barrier that prevents African Americans from executing an advance directive. There are two types of death related conflicts, they are : Predatory death anxiety Existential death anxiety Review of Related Literature (Fear of Death Anxiety)

26. Methodology • Variables • Population • Instrumentation & Data Collection • Sampling Procedures • Research Design • Analyses of Data

27. Independent Predictor Variables

28. Research Instrument • The Jordan Advance Directive Measurement Scale • The standardization results of The Jordan Advance Directive Measurement Scale produced a Cronbach’s Alpha score of 0.87 and a test re-test reliability score of 0.83. Concurrent validity measurement results yielded an r value of 0.81. Predictive validity measurement results yielded an r value of 0.71.

29. Sampling Procedures • The Stratified Systematic Random Sampling Design

30. Research Design • Multivariate Analysis • Non-experimental • Correlational • Quantitative

31. Statistical Analysis of Data • Forward Stepwise Multinominal Logistic Regression Analysis • Logit (p) = a + b1 x1 + b2 x2 + b3 x3 . . .

32. Statistical Analysis of Data (cont’d) • To test each null hypothesis the following statistical tests were computed:

33. Statistical Results Generated for Each Hypothesis

34. Statistical Analysis of Data (cont’d) • The Predictor model was produced by computing the likelihood ratio tests Which are included in the following table:

35. Graphical Representation of Null Hypothesis One Graphical Representation to the response to the set of variables used For Null Hypothesis One. Graphical representation presents normal distribution.

36. Graphical Representation of Null Hypothesis Two Graphical Representation to represent the set of variables used for Null Hypothesis Two. Graphical representation presents normal distribution.

37. Graphical Representation of Null Hypothesis Three Graphical Representation to represent the set of variables used for Null Hypothesis Three. Graphical representation presents normal distribution.

38. Graphical Representation of Null Hypothesis Four Graphical Representation to represent the set of variables used for Null Hypothesis Four. Graphical representation presents normal distribution.

39. Graphical Representation of Null Hypothesis Five

40. Graphical Representation of Null Hypothesis Six

41. Graphical Representation of Null Hypothesis Six

42. Comparison of Three Mean Clusters Combined Confirmation Results

43. Implications • As the need for progressive initiatives increases, professionals such as social workers, nurses, clinicians, physicians and health care providers should prepare a plethora of information to distribute to the African American Baptist adult population on the benefits of completing an advance directive. • Additionally, professionals should strategically prepare to communicate and engage clients in the area of death and dying, in a way that offers empowerment and increases autonomy. This discourse would allow questions, concerns, anxieties and barriers that impede the progress of completing forms that are beneficial to African American Baptist adults to be recognized. • Social workers and practitioners must begin to analyze the environment from which patients reside. This practice will give an insight on effective ways to introduce the concept of the completion of an advance directive in the African American Baptist community.

44. Implications (cont) • Trainings in reference to the benefits of the execution of an advance directive should be incorporated in the continued educational process. More importantly, to become more effective change agents the emphasis to expand knowledge on end-of-life care choices, concerns, beliefs and contention must be recognized by the social work profession. • Social work curriculum dealing with the following areas: racism, fear of death anxiety and cultural mistrust could infuse how those variable influences the execution an advance directive and other health care documents as it relates to the African American population.

45. Recommendations • Conduct future studies that obtain additional data describing different demographic, social and cultural variables and the degree to which they influence the execution of advance directives. • Replicate the current study on African American adults that are not affiliated with the Baptist denomination, but other religious denominations. • Establish a better working relationship between medical professionals and patients to allow for the discourse of the topic of end-of-life care. • Offer professional credits (CEU’s and certification of completion) for professionals who attend trainings in reference to the completion of advance directives/ end-of-life care planning. • Conduct future studies on ways to minimize the fear of death anxiety as it relates to African American Baptist adults and the execution of advance directives.

46. Recommendation (cont’d) • Create culturally sensitive programs that encourage end-of-life planning.